Letters

To the Editor: We thank Harris and Buchbinder for their focus on interventional pain procedures.1 However, their description of the procedure they discuss has not been standard practice in pain medicine in Australia for many years. They misrepresent the Medicare Benefits Schedule (MBS) number 39013 to solely include facet joint injections, whereas it includes local anaesthetic medial branch blocks, which are an evidence-based diagnostic test for posterior elements as a source of spinal pain, and can be therapeutic in their own right.2 The number needed to treat (NNT) is the number of patients that need to be treated for one to benefit compared with a placebo or sham in a clinical trial. The ideal NNT is one. After a positive medial branch block response, radiofrequency medial branch neurotomies — a procedure with an NNT ranging from two patients3 to 4.4 patients4 treated for one patient to receive effective relief of spinal pain — creates a “therapeutic window” in which ongoing spinal rehabilitation can occur. From the 35 000 MBS number 39013 procedures performed in 2012, we can infer that fewer than 0.5% of Australians with spinal pain have facet joint injections and medial branch blocks in a 12-month period. Contrary to the comments of Harris and Buchbinder, lumbar transforaminal epidural steroid injections are effective for the treatment of radicular pain associated with disc protrusion, with an NNT of 2.7,5 and in conjunction with active pain strategies may forestall spinal surgery. Before impeaching facet joint injections and medial branch blocks, and thereby medial branch neurotomies, as well as lumbar transforaminal epidural steroid injections, Harris and Buchbinder should consider: interprofessional patient-centred approaches are key; pharmacological management is often ineffective; their view does not reflect the current practice of Australian pain medicine physicians; these procedures help people struggling to continue in social roles and maintain quality of life, so they help to reduce the economic impact of spinal pain on Australian society. We support education to improve evidence-based practice of interventional procedures.

Stephanie J Davies · Malcolm N Hogg · Eric J Visser

In reply: We thank Bogduk for his comments, but, based on previous reviews and some comparative studies,1-4 do not consider the transforaminal route to be clearly and consistently superior to the interlaminar route for radiculopathy. Further, we note that when the evidence for transforaminal injections is isolated to placebo-controlled trials, the evidence is based on very few studies. The largest of these showed marginal short-term (2-week) improvement in the steroid and local anaesthetic group over the saline group for the primary outcome (leg pain), an effect that was not sustained by 4 weeks.5 Short-term relief is a common finding in studies that use local anaesthetic in the active group. We consider the evidence for the effectiveness of transforaminal steroids over placebo to be neither strong nor consistent (within or between studies). We suggest that the gem in the bathwater be subject to more scrutiny and weighed against the risks and costs. We thank Davies and colleagues for their comments about medial branch blocks and transforaminal epidural steroid injections. We have addressed the latter in our response above. Our article does not extend beyond the use of steroids to procedures such as neurotomy, so we have not commented on this procedure here. Regarding medial branch blocks, we note that in a systematic review mentioned by Davies and colleagues, each of the randomised trials showed no significant difference in the response between groups treated with steroid and those treated with local anaesthetic alone.6 This reinforces our point that steroid injections in the spine have no specific therapeutic effect beyond natural history, the effect of any concomitant treatment or any placebo effect.

Ian A Harris · Rachelle Buchbinder

To the Editor: Silbert and colleagues highlight the benefits of peer-assisted learning (PAL).1 They allude to the number of overseas medical schools that provide tutor training programs, and to the possibility that Australian medical students are missing out on this opportunity. We agree that PAL is useful, but not all Australian medical students have been deprived. Since 2008, Monash University has been running VESPA (Vertical ...

Joanna H-M Tai · Sumudu P Cooray · Jonathan K Kam

To the Editor: Silbert and colleagues propose that teaching skills training should be compulsory for all medical students, to be used in peer-assisted learning programs and later in postgraduate roles.1 As the quality of student training will have an enduring impact on the provision of quality care and patient safety, the responsibility for this important role should be entrusted to a select group rather than ...

Michael Pearson

In reply: We agree that the quality of student training and competence of those delivering it are of utmost importance. However, we disagree with Pearson’s opinion that teaching “should be an honour bestowed on a few rather than a rite or obligation for all” and that only these “honourable few” should be trained.1 Involvement in any teaching confers benefits to both tutors and tutees1-3 and, ...

Benjamin I Silbert · Stephanie J P Lam · Robert D Henderson · Fiona R Lake

To the Editor: I thank Cameron and colleagues for their timely report,1 particularly in the context of publicity for a new self-help book by economist Emily Oster, which questions advice about avoiding alcohol during pregnancy.2,3 I note with interest that Cameron et al’s study reports that proportionally more of the women who consumed alcohol beyond the first trimester were older and more highly educated. Oster has ...

Tracy W Soh

Clinicians should sometimes just say no to the “just in case” peripheral intravenous catheter to reduce harm caused.

Claire Dendle · Rhonda L Stuart · Diana Egerton-Warburton

The coincident seasonality of active TB cases and vitamin D deficiency suggests that low vitamin D levels may increase the likelihood of reactivation of tuberculosis. Vitamin D testing and supplementation is therefore recommended for high-risk groups.

Jennifer H MacLachlan · Benjamin C Cowie

The PSA test is an important clinical tool that must be considered in its correct context.

Kenneth A Sikaris · Bronwen A Ross · Teck Y Khong

The monoclonal antibody bevacizumab is used to treat symptomatic bleeding in patients with hereditary haemorrhagic telangiectasia; the bleeding often recurs in time, and it seems it may be effective and safe to re-treat with bevacizumab.

Gwo Yaw Ho · Edward Zhong · Boris Chern

Whenever a case of “deathcap” mushroom poisoning occurs, the possibility of ongoing risk of poisoning should be investigated by public health units.

Andrew J Pengilley · Paul M Kelly

The increasing use of psychotropic medicines has led to a need to understand the safety of antipsychotics in pregnancy.

Roisin N Worsley · Heather Gilbert · Jayashri Kulkarni

Is it fair that we, as colleagues in health care, should collude in keeping the truth away from the unsuspecting person walking through the door?

Navin I Dadlani

Recent articles in the MJA reflect the continuing polarisation of the debate on prostate-specific antigen-based screening and the extent to which major clinical trials reveal whether lives are saved by intervention and/or watchful waiting.

George G Miklos

Prostatic-specific antigen screening for prostate cancer is not recommended, but how does this help reduce the death rate from prostate cancer?

Mark Faigen